Intake form

Name *

Email address *

What is your primary fitness goal?

Are you currently pregnant or postpartum?

What is your age range?

Do you have any existing medical conditions?

What is your current fitness level?

What types of exercise do you prefer?

Please select at least one option.

Cardio

Strength training

Yoga

Pilates

Outdoor activities

Are you currently following a specific diet or nutrition plan?

If yes, please specify your diet or nutrition plan.

What is your primary source of motivation for fitness?

Please select at least one option.

Health

Appearance

Mental well-being

Social interaction

Challenge

Which service or services are you interested in?

Please select at least one option.

Pregnancy Program

Postpartum Rehabilitation Program

EmpowHER Online<br/>

General Women's Nutrition and Fitness Program

Additional questions or comments

AP Impacts LLC